Considering the advantages of a full-electric hospital bed over a semi-electric one, it is easy to see why patients and caregivers might prefer them. But want and need are two different things—especially according to Medicare.

“The hardest thing to figure out is if [the patient] needs a semi- or full- [electric bed]—if they need it or just want it,” says Nema Davis, president of Davis Mobility Company, of Irving, Tex.

For her company, and others like it, beds are sometimes considered a loss leader. “A lot of companies only provide full electrics, then they just get billed for semis,” Davis says. “You lose money, but it is a customer service. I just look at what the customer’s need is. If he or she really needs a full-electric bed, [I provide one]. There has to be a point when you are human, too.”

However, the advance beneficiary notice (ABN) that the Office of Management and Budget passed last summer may allow Davis’ humanism and the bottom line to intersect more often. To gauge providers’ reactions to the form—which lets them accept Medicare assignment for equipment with features that are not covered by Medicare and then collect the difference between the allowable reimbursement and the real cost of the equipment from the beneficiary—Dealer/Provider spoke with bed providers around the country. Most, like Bob Lichtenstein of Hollywood Medical Supply, Hollywood, Fla, were taking a wait and see approach until the Centers for Medicare & Medicaid Services (CMS) published its final rules in January.

“My understanding at this point is, yes, it has been approved; however, we don’t have final rules out,” says Lichtenstein, who is also vice president of the Florida Association of Medical Equipment Services. “Until we have final rules, we may inadvertently make an error due to lack of knowledge. I believe most providers are staying on the sidelines at this point. We’ve waited this long, we can wait a little bit longer.”

However, since the difference between a full- and a semi-electric bed is a fairly clear case of a definite feature upgrade and not just a difference of quality of materials and workmanship, some providers were going ahead and using the form before the rules were finalized. One such provider was Vincent DeStigter, president and CEO of Western Health Care Industries Inc of Jackson, Calif.

Prior to the January publication of the final rules, DeStigter used the form twice for bed reimbursement. In both cases, he received full payment. “Medicare is not even going to recognize this, all they are going to do is a pass-through on this thing,” he says. “The only time there is going to be some question about this product being used is when the beneficiary [complains] because of having to pay a bill and they think they didn’t have to or there’s a review done.”

In general, says DeStigter, beds are an easy item to get reimbursed. Since most doctors dislike prescribing beds because they worry that once a patient ends up in a hospital bed they will never get out of it, it is rare that someone who does not absolutely need a hospital bed gets one, DeStigter says. About 90% of the beds he provides go to hospice patients and are, on average, used only for a few weeks.

With every new opportunity there is a cost, and the way CMS wrote the new ABN form seems to express its concern that beneficiaries could be talked into spending their own income on unnecessary features by savvy HME salespeople. The form makes clear that the beneficiary is responsible for the cost of the item in case Medicare denies payment and gives the beneficiary the opportunity to refuse to receive the upgraded item.

However, both DeStigter and Lichtenstein say it is unlikely that the providers that remain in the HME marketplace will use the upgrade provision associated with the new ABN form to defraud patients and the government. “The bad people can’t play in this marketplace anymore,” DeStigter says. “First of all, we get scrutinized by the Medicare system and they actually visit our facility, and then we are scrutinized by the State of California. As far as fraud and abuse are concerned, you are always going to find a bad player, but that bad player can be identified in 5 seconds. I have told the [durable medical equipment regional] carriers this for years, ‘If somebody comes along all of a sudden now and sells every person that comes to them an electric hospital bed with an ABN, you ought to go visit them. Find out whether the doctor really wanted the patients to have electric beds or not. If not, call 10 out of the 100 that provider bills....The carrier can identify [fraud and abuse] in a minute; they’ve got the opportunity. The real fact is that [the ABN] is an opportunity for our industry, but not for fraud and abuse.”

Lichtenstein echoes DeStigter, saying that the rules governing the honest providers are the problem and not the danger of dishonest providers sneaking through a bureaucratic backdoor. “Most of us, while we don’t understand the reasoning or the whys or the wherefores, abide by the program, so we do what we do and if we can’t do it, we’ll say no and won’t do it at all,” he says.

Those, like DeStigter, who have decided to enter into the uncharted territory of the ABN have shown that there is little reason to wait. “The ABN is going to be a help for us, and if we use it properly, it is going to be a big help for us,” he says.

C.A. Wolski is associate editor of Dealer/Provider.